Why do systems for responding to concerns and complaints so often fail?

The heading above is the title of a 2021 article by Graham P. Martin, Sarah Chew and Mary Dixon-Woods (the authors) - the full title of the article being 'Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff?' And the graphic is from the THIS.Institute website where you can access this study.

I recently read this article with great interest - both because it makes such good sense and also in relation to some work that I am currently progressing to do with complaints. You may have read this article already, but if not, then I strongly recommend that you do. My aim in writing and posting my summary of this article is to share the content more widely as I think that what it contains has relevance to complaint handling in general and may also be of interest to mediators. And to say that I'm only giving a flavour of the article here - with my apologies in advance to the authors for any misunderstandings or misrepresentation.

Introduction

The value of concerns and complaints (with a focus on the NHS) is acknowledged in this article, but there is also reference to earlier studies which have found that the mechanisms for raising complaints and concerns often disappoint those who use them, or they fail to produce a resolution that meets expectations. The authors comment that this disappointment often breeds more general scepticism about the value of the process, such that staff and patients may see raising concerns or complaints as a futile or even risky pursuit.

This led them to conduct a qualitative study which draws on a wider study of culture around openness in English healthcare organisations, funded by the Department of Health and Social Care’s Policy Research Programme. This sub-study involved qualitative interviews with staff, patients and family members in six English NHS organisations (three acute hospital trusts, two community and mental healthcare trusts and one ambulance trust), sampled for diversity of organisation type, population served and approach to implementation of the initiatives. And comprised 88 interviews in total (70 staff; 18 patients and family members).

What I found so interesting in this article is well set out in a paragraph which says: "In this paper, we argue that this location of complaints and concerns - at the interface between highly personalised motivations and consequences, and systems and processes oriented towards organisational objectives - is crucial to understanding what goes wrong in complaints and concerns processes and how to improve them."

Jürgen Habermas's Systems Theory

The authors use Jürgen Habermas’s systems theory to analyse their qualitative interviews, to identify structural features that militate against processes and outcomes that satisfy complainants and to offer new insights into what might be done to secure improvement.

I have found that there is a huge literature relating to Habermas’s theory and its applications - and that the theory is well explained in this article. My understanding of the theory from this and from other readings are that we live our lives in two distinct spheres: there is the everyday world in which we interact socially with family and friends (which Habermas refers to as the Lifeworld) and there is the professional/administrative sphere within which we interact with institutional authority (which Habermas calls the System).

Our Lifeworld is based on shared understandings and meanings and so our day-to-day actions here are mainly communicative. The aim of the System is to achieve its own aims and to serve the interests of institutions and organisations. So actions here are mainly instrumental - in effect the System uses its power to 'manipulate' individuals to achieve its own aims and functions - and these aims may not coincide with those of individuals.?

Habermas makes a distinction between the Lifeworld communicative rationality and System functional rationality. Communicative rationality is the capacity of humans to engage in deliberation, constructive disagreement and argument towards consensus. Functional rationality belongs in the domain of the System and allows coordination between humans in pursuit of already-agreed objectives and criteria of success, without the need for conscious will on the part of those involved.

The authors explain that the System and Lifeworld are interdependent. And say that Habermas notes that in practice the logics of the System often intrude into the Lifeworld, with his idea of the “colonisation” of the Lifeworld by the System. Here norms, rules and objectives that should be a matter of negotiation may be subject to 'reification' in that "they are removed from our communicatively rational mechanisms of developing agreement, such as argument and democracy, and thus from collective human control." Examples of Lifeworld colonisation in healthcare include how bureaucratic or medical concerns may come to dominate consultations, resulting in struggles for the concerns of the Lifeworld to be heard.

?The authors go on to suggest that "Like the clinical encounter, concerns and complaints lie “at the seam between the system and lifeworld". They are located where Lifeworld and System concerns intersect, and so communicative rationality is most vulnerable to colonisation."

Findings

What I valued particularly about this article was that it included the views and experiences of both patients and staff. Many participants in their study described frustrations with systems and processes that seemed ill-equipped to deal with concerns of the kinds raised. And the authors comment that while functionally rational processes are well equipped to deal with simple, readily categorised concerns and complaints, they are less well placed to respond adequately to concerns and complaints that are complex, cross-cutting, or irreducible to predetermined criteria for redress and resolution. So there is a mismatch between the expectations of those raising concerns and complaints, and the outcomes that processes were designed to achieve.

Common to many participants’ accounts in this study was a sense that the systems they encountered were poorly designed and poorly realised. Participants described obscure procedures for raising concerns and complaints, long delays in responding to concerns, and attempts to resolve cases that they found unsatisfactory. They described systems that seemed poorly thought through and poorly resourced, which moved along achingly slowly, and where the onus lay on them as complainants to keep things moving.

There was also a sense that those within the System were more concerned with addressing the needs of the bureaucracy itself than with either resolving concerns or seeking to improve the quality of healthcare provision. A telling quote is that "As one manager noted, some of the indicators by which processes were governed were focused explicitly on the task of managing cases through to closure, with little regard for the quality of those processes or satisfaction with their outcomes."

The study findings included that "relatively straightforward concerns about uncontroversial aspects of organisational function, then, were generally well served by the functional rationality of this bureaucracy. Other pathways were more prone to misaligned expectations and objectives among those involved". There was also the finding that "Participants thus found their complaints and concerns channelled into various response pathways. But often, the issues they raised were not easily allocated without significant contortion." And that "Such processes, participants perceived, stripped the issues they raised of meaning in the interests of packaging them in a form that could be processed."

Patients in this study did not have insider knowledge and so moulding their complaints into the shapes expected by bureaucracies was all the more challenging. And it was the case that the scope of the issues that troubled them often extended through time and space. The authors explain how misdiagnosis, ill-coordination between teams, and other forms of poor-quality care were often highly consequential for patients and relatives, but fitted complaints and concerns systems poorly. The authors also comment on how impacts in the Lifeworld demanded attention and resolution. And that negative impacts can be profound, but the bureaucracies that the patients encountered were not set up to acknowledge these impacts, let alone to address them.

Indeed, the authors consider that "much of the frustration and disappointment described by participants seemed, to stem from systems whose ability to respond was limited by their own functional rationality, expressed in categorisation processes, terms of reference, and pathways for response." And also that "functional rationality comes to dominate these processes".

The article includes recognition that many staff knew that the system wasn't 'working' with regard to their own and to patients concerns and complaints. Interviews with participants involved in administering organisations’ responses to concerns and complaints suggested that they were well aware of the shortcomings of the systems they worked in, but often could do little to moderate their effects. Instead, the functional rationality of the System took over and gave rise to instrumental rationality on the part of its actors: consciously or unconsciously, preoccupation with meeting the preordained needs of the bureaucracy eclipsed interest in dialogue with people raising concerns and complaints, especially when those concerns and complaints were not set out according to the System’s logic.

Discussion

In the Discussion section of this article the authors say that "Many participants’ concerns and complaints were to be found at the seam of the System and the Lifeworld: while they might concern technical problems that required a technical solution, they often also related to things that were not reducible to functional rationality. They required communicative action - both to understand, make sense of and appropriately resolve the impacts on the individual or group complaining, and to work out the implications for organisations themselves."

And interestingly the authors observe that their findings challenged narratives that portray poor handling of concerns and complaints solely as a consequence of sinister or malign organisational actors seeking to impose silence. They do not deny that this does occur (saying it is egregious where it does), but say that it does not fully explain the limitations of the systems’ abilities to address the expectations of those raising concerns and complaints. Instead, their analysis parallels Habermasian accounts of Lifeworld colonisation in micro-level healthcare encounters, where the ‘voice’ of the Lifeworld is silenced through operation of a functional rationality that prioritises the efficient resolution of discrete, manageable ailments over the development of shared understanding between patients and clinicians.

The authors also observe that "organisational systems for processing concerns and complaints may parse, repackage and process them in ways that achieve formal objectives but leave those who have sought to give voice feeling unheard and dissatisfied - all without necessarily involving ill-intent on the part of those who design and operate systems."

Conclusion

The paper concludes by asking a key question about what a better way of responding to these kinds of complaints and concerns might look like. And says that "The task, therefore, is not to displace functional rationality with communicative rationality - a counter-colonisation of the System by the Lifeworld - but rather to ensure that each resides in its proper place, which might include a role for communicative rationality in some parts of the System."

From their and other studies they found that "a common feature of approaches introduced in organisations was the role of individuals responsible for handling concerns and complaints in making initial judgements about whether they were amenable to resolution through existing functionally rational processes, or whether they required further discussion with the complainant, for example to articulate or specify the nature of the problems more fully. They thus involved the creation of forums governed by communicative rationality, alongside existing functionally rational processes."

The authors also say that "To realise the potential for achieving communicative action of this kind of forum, it may also be necessary to ensure that those with concerns and complaints are supported in raising them." And that "The goal is not to attempt to disband processes that, in many cases, appeared very effective in doing what they were designed to do. Rather, it is to ensure that alternative arenas exist for the expression of concerns and complaints that cannot be resolved through the application of functional rationality, and to help staff and patients with concerns of this kind to access these arenas and frame their concerns in ways most likely to elicit an appropriate, deliberative response."

The concluding paragraph of this article says: "Government inquiries and empirical studies have repeatedly highlighted the frustration caused by healthcare organisations’ responses to patients, families and staff when concerns and complaints are raised, and the risks these responses pose to quality and safety. Our study shows how these problems can in part be understood to arise from processes designed to achieve certain reasonable but narrowly defined objectives, following the functional rationality characteristic of the System, as described by Habermas. This has important implications for how best to improve such organisational responses, in particular by providing supplementary means of addressing those complaints or concerns that are not reducible to functional rationality, and instead demand communicative action."

And finally

There is so much to commend in this article. I found the theory of the Lifeworld and the System - how these intersect and interact - to be a helpful concept in revealing and better understanding the frustrations and disappointments of those who make and work with complaints. It brought home to me the importance of complaint process design and the need to take a holistic and restorative approach. And it reinforced the magnitude of communication - including the importance of complaint handlers having and taking the time to find out what matters - not just what happened (or didn't), but also understanding and taking into account the emotional and psychological needs of all concerned.

Reference

Martin, G.P., Chew, S. and Dixon-Woods, M., 2021. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualitative study. Social Science & Medicine, Vol. 287, p.114375.